Faculty of Medicine and Health Sciences
United Arab Emirates University
VSE Clinical Medical Elective Application
PART A: To be completed in full by applicant:
Surname Given DOB (yy/mm/dd) Gender Citizenship
Street Apt.# City Country Postal/Zip Code Phone Number Fax Number
E-mail address:___________________________________________ Fax number: __________________________
Name of Medical
Current year of study:__________ Length of program:___________
Expected date of graduation:___________________________
List in order of preference your elective choices and dates of your chosen block(s):
First Choice: Second Choice:
Date of block: Date of block:
yy/mm/dd to yy/mm/dd yy/mm/dd to yy/mm/dd
NOTE: If you have already identified a physician or hospital, please indicate, otherwise the
Medical Education Office will assign a supervisor to you at the time of processing; however, a
choice of discipline MUST be indicated.
PART B: To be completed by the Dean's Office of home university:
Mr. / Ms.______________________ is a student in good standing currently registered in the
_______year of a ________year program at this university.
The student WILL / WILL NOT carry liability insurance in the amount of ___________AED
(provided by the home university). This student IS / IS NOT authorized and approved to
complete electives for academic credit at other institutions.
General assessment of student's clinical ability: Above Average / Average / Below Average
Student's academic standing: Above Average / Average / Below Average
Full address of home university:
School Seal / Stamp
Signature of School
Name and Title of
PART C: To be read and signed by applicant:
I understand that this application will not be processed without fee payment (which may be
subject to change without prior notice). If I cancel my placement with less than 4 weeks' notice I
understand that a processing fee of 50USD will be retained by FMHS. If I request that any
change be made to the dates or specifications of my placement after it has been confirmed, an
additional 50USD processing fee will be assessed and must be paid before my placement begins.
I have read the immunization requirements included with this application and confirm that I will
adhere to all requirements and will be prepared to provide proof of said immunization status while
completing my placement.
I understand that all clinical instruction occurs in English. I certify that both my written and spoken
English skills are currently fluent. In signing and submitting this application I certify that all
information provided is complete and accurate.
Signature of Applicant:____________________________ Date:__________________